Australian Base Implementation Guide

This page is part of AU Base v4.0.0 based on FHIR R4. For a full list of available versions, see the Directory of published versions

1.0 StructureDefinition-au-pathologyreport

AU Pathology Report [FMM 1]

This profile defines a diagnostic report structure to represent a pathology report issued by a diagnostic service provider in an Australian context. This profile is intended to be capable of supporting reporting for all pathology disciplines (e.g. including microbiology, histopathology, cytology, blood transfusion) with the exception of genomics.

Identifiers

These definitions, defined as profiles of Identifier, represent common data held in the DiagnosticReport.identifier element:

Extensions

No extensions are used in this profile.

Boundaries and relationships

This profile does not provide full support for structured pathology reporting. It is expected that this support is best handled by a set of profiles that represent the structured reporting requirements for each specific protocol (see for example RCPA’s structured pathology reporting of cancer); this is not in the scope of this implementation guide at this time.

Usage Notes

When constructing the report:

  • a local identifier is sent with a HPI-O scoped identifier namespace if there isn't a local namespace available (see the FAQ) for more information
  • code matches one Observation.code referenced in result
  • effective[x] is the earliest specimen collection date time
  • performer is sent as one Organization (pathology laboratory) and one or more PractitionerRoles (pathologist)

For a report of a multi-test study or panel:

  • result is sent with the Observation representing the study / panel
  • code is sent with the same code in that study / panel Observation
  • the individual component tests are referenced by that Observation (Observation.hasMember) and not the DiagnosticReport

If the pathology laboratory is a discipline specific laboratory then one of the appropriate discipline specific value sets may be more suitable for use than the entire reporting set available in the profile:

Examples

No examples are available for this profile.

1.0.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org.au/fhir/StructureDefinition/au-pathologyreport

This profile defines a diagnostic report structure to represent a pathology report issued by a diagnostic service provider in an Australian context.

This profile builds on DiagnosticReport.

This profile was published on 2021-07-19 as a draft by Health Level Seven Australia (Orders and Observations WG).

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA pathology report in an Australian healthcare context
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | AU Diagnostic Request | CarePlan)Pathology order
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ1..*CodeableConceptService category
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject Σ1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ1..1Time of specimen collection
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(AU Diagnostic Result | AU Pathology Result)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA pathology report in an Australian healthcare context
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*Identifier, AULocalOrderIdentifier, AULocalReportIdentifier, AUAccessionNumberBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | AU Diagnostic Request | CarePlan)Pathology order
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category Σ1..*CodeableConceptService category
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject Σ1..1Reference(Patient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ1..1Time of specimen collection
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(AU Base Specimen)Specimens this report is based on
... result 0..*Reference(AU Diagnostic Result | AU Pathology Result)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

1.0.2 Quick Start

Below is an overview of the required search and read operations.

Summary of Search Criteria for StructureDefinition-au-pathologyreport

none defined

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